Evaluation of complication rates of pediatric spinal procedures in which a polyethylene glycol sealant was used

Cerebrospinal fluid leakage after intradural spinal surgery in children

PURPOSE

This study aimed to establish the incidence of CSF leakage in children and associated complications after intradural spinal surgery in three tertiary neurosurgical referral centers and to describe the treatment strategies applied.

METHODS

Patients of 18 years or younger who underwent intradural spinal surgery between 2015 and 2021 in three tertiary neurosurgical referral centers were included. Patients who died or were lost to follow-up within six weeks after surgery were excluded. The primary outcome measure was CSF leakage within six weeks after surgery, defined as leakage of CSF through the skin. Secondary outcome measures included the presence of pseudomeningocele (PMC), meningitis, and surgical site infection (SSI).

RESULTS

We included a total of 75 procedures, representing 66 individual patients. The median age in this cohort was 5 (IQR = 0-13 years. CSF leakage occurred in 2.7% (2/75) of procedures. It occurred on days 3 and 21 after the index procedure, respectively. One patient was treated with a pressure bandage and an external lumbar drain on day 4 after diagnosis of the leak, and the other was treated with wound revision surgery on day 1 after the leak occurred. In total, 1 patient developed a PMC without a CSF leak which was treated with wound revision surgery. SSI occurred in 10.7%, which included both cases of CSF leak.

CONCLUSIONS

CSF leakage after intradural spinal surgery in the pediatric population is relatively rare (2.7%). Nevertheless, the clinical consequences with respect to secondary complications such as infection and the necessity for invasive treatment are serious.

Incidental durotomy in the pediatric spine population

OBJECTIVESpine surgery is less common in children than adults. These surgeries, like all others, are subject to complications such as bleeding, infection, and CSF leak. The rate of incidental durotomy in the pediatric population, and its associated complications, has scarcely been reported in the literature.METHODSThis is a retrospective chart review of all pediatric patients operated on at Wake Forest Baptist Health from 2012 to 2017 who underwent spine surgeries. The authors excluded any procedures with intended durotomy, such as tethered cord release or spinal cord tumor resection.RESULTSFrom 2012 to 2017, 318 pediatric patients underwent surgery for a variety of indications, including adolescent idiopathic scoliosis (51.9%), neuromuscular scoliosis (27.4%), thoracolumbar fracture (2.83%), and other non-fusion-related indications (3.77%). Of these patients, the average age was 14.1 years, and 71.0% were female. There were 6 total incidental durotomies, resulting in an overall incidence of 1.9%. The incidence was 18.5% in revision operations, compared to 0.34% for index surgeries. Comparison of the revision cohort to the durotomy cohort revealed a trend toward increased length of stay, operative time, and blood loss; however, the trends were not statistically significant. The pedicle probe was implicated in 3 cases and the exact cause was not ascertained in the remaining 3 cases. The 3 durotomies caused by pedicle probe were treated with bone wax; 1 was treated with dry Gelfoam application and 2 were treated with primary repair. Only 1 patient had a persistent leak postoperatively that eventually required wound revision.CONCLUSIONSIncidental durotomy is an uncommon occurrence in the pediatric spinal surgery population. The majority occurred during placement of pedicle screws, and they were easily treated with bone wax at the time of surgery. Awareness of the incidence, predisposing factors, and treatment options is important in preventing complications and disability.

CSF-Related Complications After Intradural Spinal Tumor Surgery: Utility of an Autologous Fat Graft

Object:

The incidence of cerebrospinal fluid (CSF)-related complications after intradural spinal tumor (IST) surgery is high and reported in up to 18% of patients. However, no efficient way to prevent those complications has been reported so far. Treating these complications may require prolonged bed rest, re-exploration, external lumbar drain, use of antibiotics, and possible precipitation of other complications. To alleviate the risk of CSF-related complications, we prospectively adopted the intraoperative use of autologous fat grafting after IST surgery.

Methods:

This is a perspective analysis of 37 cases (out of 40 cases series) that a prospective use of abdominal fat autograft was applied during dural closure. After the tumor was resected and the dura closed, we used the Valsalva maneuver to ensure watertight closure. CSF leak was prevented with the enforcement of suture with a fat autograft as necessary. In addition a thin layer of fat tissue was then placed over the dura to obliterate any dead space. Fibrin glue was then applied over the graft. Filling the dead space with the fat graft prevented a low-pressure space in which CSF could pool and form a pseudomeningocele.

Results:

After adopting the fat autograft technique, we did not observe any post-surgery CSF-related complications in any of these patients.

Conclusions:

The prospective use of autologous fat grafting can ensure watertight dural closure and obliterate the dead space created during surgical exposure and bone removal. This technique significantly reduces, and may completely eliminate, postoperative CSF-related complications in patients with ISTs.

Spinal sealant system provides better intraoperative watertight closure than standard of care during spinal surgery: a prospective, multicenter, randomized controlled study

STUDY DESIGN

Prospective, 3:1 randomized, single-blind, multicenter investigational study.

OBJECTIVE

To assess the safety and efficacy of a low-swell spinal sealant when used as an adjunct to sutured dural repair compared with standard of care methods to obtain watertight dural closure in subjects undergoing spinal surgery.

SUMMARY OF BACKGROUND DATA

Watertight dural closure is paramount in spinal surgery to avoid complications of cerebrospinal fluid leak. Prior reports have proven the efficacy of a synthetic, absorbable polyethylene glycol (PEG) hydrogel sealant in spinal surgery compared with standard of care. Given the potential concerns of swelling in spinal applications, the hydrogel was modified to a low-swell formulation.

METHODS

The primary endpoint was success rate in obtaining intraoperative watertight dural closure in subjects receiving PEG hydrogel sealant versus a control group of subjects receiving any standard method designed to provide intraoperative watertight closure. Subjects were evaluated at discharge and at 30 and 90 days postprocedure for cerebrospinal fluid leaks, surgical site infections, and adverse events.

RESULTS

Between May 2007 and May 2009, 98 subjects (74 PEG hydrogel spinal sealant, 24 control) were randomized at 14 clinical sites in the United States. Patients treated with the PEG hydrogel spinal sealant had a significantly higher rate of watertight closure than the control (98.6% vs. 79.2%, P = 0.003). No statistical differences were seen in postoperative cerebrospinal fluid, infection, and wound healing. No neurological deficits were seen attributable to the sealant.

CONCLUSION

The low-swell PEG hydrogel spinal sealant evaluated in this study has been proven safe and effective for providing watertight closure when used as an adjunct to sutured closure of intentional durotomies during spinal surgery. PEG hydrogel sealants have again proved superior to other standard of care technologies for safe, efficacious dural closure.

LEVEL OF EVIDENCE

2.

Evaluation of complication rates of pediatric cranial procedures in which a polyethylene glycol sealant was used

OBJECT

Polyethylene glycol (PEG) sealant in conjunction with standard closure techniques is effective in preventing CSF leaks after cranial procedures in adult patients, but the safety of PEG sealant in the pediatric population has not been shown.

METHODS

The authors performed a retrospective analysis of pediatric neurosurgery patients (0-18 years of age) treated from 2005 to 2010 at The Johns Hopkins Hospital. There were 163 patients who underwent cranial surgery with the use of PEG sealant as an adjunct to standard closure techniques. There were 92 males and 71 females with an average age of 10.2 years. The incidences of revision surgery, CSF leak, meningitis, and neurological deficit were recorded.

RESULTS

In the cohort's 90-day postoperative clinical course, the authors found that 4 patients (2.5%) required revision surgery, 2 patients (1.2%) developed a CSF leak, 4 patients (2.5%) developed a superficial skin infection, and 1 patient developed meningitis (0.6%) with no deaths or neurological deficits observed.

CONCLUSIONS

PEG sealant appears to be a safe adjunct to standard dural closure in pediatric cranial surgery patients to augment dural closure.